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Upon review of the Duplication of Benefits Reporting Form,the City may request additional information related to <br /> the funding sources listed above. Please maintain documentation for each of the sources of funds acquired during <br /> the period of performance for this agreement. <br /> I hereby certify that I have read the above certification, and that the information and my statements provide <br /> herein by me are true and correct to the best of my knowledge, and by my signature on this document <br /> acknowledge my understanding that any intentional or negligent misrepresentation or falsification of any of the <br /> information in this document could subject me to punishment under federal and/or civil liability and/or in criminal <br /> penalties,including but not limited to fine or imprisonment or both under Title 18,United States Code,Sec. 1001 <br /> et seq.and punishment under federal law. <br /> /42 Sfe (4-11 46) <br /> gfrt#141'& <br /> Printed Name Signature <br /> Title Date <br /> EVE E T T Everett Forward Grant Program I Subrecipient Agreement I Page 17 <br /> MIMS WASHINGTON <br />